Transitioning to Transradial

St. Joseph’s Hospital of Atlanta is using radial access to increase patient comfort with a cafe-style recovery room

By:

Dave Fornell

July 20, 2010

Transradial access is slowly gaining ground in the United States as more physicians make the switch due to greatly reduced bleeding complications, increased patient comfort and earlier ambulation. St. Joseph’s Hospital of Atlanta is a big supporter of radial access and has taken the concept a step further by creating the first transradial recovery lounge in the country.

“I really see this as the future of cardiac care, not just as an alternative access route for percutaneous coronary intervention, but also to improve the patient experience and reduce their hospital stay,” said Jack P. Chen, M.D., FACC, FSCAI, FCCP, director of cardiac research, St. Joseph’s Translational Research Institute, Saint Joseph’s Heart and Vascular Institute, Atlanta.

Radial access is very popular outside the United States because it offers improved safety, comfort and cost savings over femoral access, which is the current U.S. standard of care, said Chen, who also directs a course to train cardiologists on the transradial technique. Femoral access site recovery usually involves heavy, uncomfortable compression of the leg. Patients are also required to lay on their back, in bed and not move for hours to ensure proper hemostasis. These discomforts are eliminated with radial access.

Most importantly, the risk of bleeding and arterial damage, the most common complications following these procedures, is essentially eliminated with the transradial approach.

Increasing Patient Satisfaction

“If you talk to any patient who has gone through a transfemoral procedure, they will tell you the worst thing is after the procedure. That’s what patients dread the most,” Chen told Diagnostic and Invasive Cardiology. “Most patients complain of the bed rest, the back pain, muscle spasms and the tremendous amount of pressure applied to their groin by a clamp or a staff member. You can spend three hours performing a complex, multidevice, multivessel bifurcation rotablator/stent case with an excellent result, but what the patient will remember is the pain from the pseudoaneurysm repair they now need.”

Radial access eliminates this vascular access risk, as well as the pain and discomfort associated with hours of bed rest, Chen said. “There is no question patients prefer this,” Chen explained.

With patients who have undergone both radial and femoral access procedures, he said the vast majority will never let him touch their legs again. This type of patient satisfaction has spread by word-of-mouth and has led to an increasing number of patients seeking radial access procedures at St. Joseph’s. “My patients are the procedure’s and my best advocates,” Chen said.

The ‘Cath Spa’ Concept

A trend in medical facility design over the past 15 years has moved away from the sterile, institutional look of traditional hospitals. Instead, more inviting, warm and friendly looking facilities are being built to make patients feel more comfortable. This concept is now being applied to the cath lab recovery room. Use of radial access allows for immediate ambulation, and thus a major revision to recovery room design, replacing beds with couches and recliner chairs.

St. Joseph’s Hospital is the first in the United States to build a cafe-like lounge exclusively for radial access patients. Chen took the idea from Ferdinand Kiemeneij, M.D., department of interventional cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands. He created the first radial access recovery room in Europe after getting the idea from a KLM airline lounge.

“The idea is to build a cafe-type atmosphere to reduce the anxiety associated with invasive heart procedures,” Chen said. “When I first approached the hospital administration with this idea, they required a bit of convincing. However, after seeing the patient satisfaction and alleviation of complications stemming from this technique, all were in agreement that this concept may well be the wave of the future.”

He said the hospital embraces the radial access approach as a new frontier in interventional cardiology and agreed to build the new recovery area. “To me, this rounded out the picture of a more patient-friendly cardiology program for what is essentially a minimally invasive catheterization/interventional procedure,” Chen said.

Patients sit in the lounge chairs for 30 minutes to an hour, only to recover from the sedation. The patients are then allowed to ambulate in their street clothes. They can walk around or sip a cappuccino, Chen said.

The recovery room has comfortable reclining chairs instead of beds and there are couches and coffee tables topped with magazines and newspapers. The recliners have attached swing-up table tops where patients can put a laptop computer and check their e-mail or surf the Internet. The idea is to eliminate the sterile, institutional appearance of most recovery rooms and to relax the patient with a more inviting atmosphere.

“We are trying to take the hospital out of the equation,” Chen said. “Patients are much more at ease than they would be in a typical hospital setting. To allow them to put on their street clothes really reduces the anxiety they have.”

The lounge was showcased and visited by many cardiologists from around the country in March, during the American College of Cardiology (ACC) Annual Scientific Sessions, which were held in Atlanta.

Improving Patient Safety

“Large-scale studies have actually demonstrated that where you put your sheath and catheter can actually improve the survival of your patients significantly,” Chen said. “I think even the critics would not disagree that this approach is much safer.”

Chen said it is really incumbent on physicians to choose the safest way of performing procedures. He points to several studies showing evidence of lower complication rates with transradial access.

“There is no question that significant mortality and morbidity are linked to major bleeding complications,” Chen said. “By taking that essentially out of the equation, we have made percutaneous coronary interventions much safer.”

Chen said radial access helps reduce bleeding complications by 70-80 percent. “It is very disheartening to have performed a successful procedure, only to encounter a serious outcome from a complication of the sheath pull,” Chen said. “It is important to note that vascular closure devices, while decreasing the ambulation time, have never been demonstrated to improve the complication rate of transfemoral procedures. Just by changing the access site, physicians can potentially make their patients live longer. In these times of health care cost containment, it is one of the rare safety precautions which is not only free, but can actually save you money.”

Device Complications

Chen said the hydrophilic coating on one brand of sheath he initially used can, on rare occasion, elicit a sterile inflammatory reaction at the access site.

One of Chen’s patients developed a small sterile abscess from this. When he apologized and treated the patient for the abscess, the patient told him that this was still much more comfortable than his previous transfemoral procedure. Even with this minor complication, the patient said they would still insist on a transradial approach if a future procedure were needed.

Take a Video Tour

Take a video tour of the transradial lounge at St. Joseph’s Hospital of Atlanta at

www.DIcardiology.net/node/37079.

Learn the reasons why the hospital embraces transradial access

www.DIcardiology.net/node/37080.

Sidebar

“Complications are lower in almost all areas with radial access. I now do the majority of my cases radially,” said Zoltan Turi, M.D., director of the Cooper Vascular Center, professor of medicine, Cooper University Hospital, Camden, N.J. He mentioned his preference for radial access during a presentation on vascular closure during last fall’s Transcatheter Cardiovascular Theraputics (TCT) 2009 in San Francisco.
He said the wrist does not have any major structures to interfere with the artery puncture. There is also less risk of hemorrhage or aneurisms using the technique, he explained.

Turi said it is also easier to find the radial artery than the femoral in many patients. To help find the artery, he places a pulse oximeter on a finger and then watches the reading as he tries to locate the radial artery with compression.